1629203310 NPI number — HEATHER COLLINS MONTGOMERY FNP

Table of content: HEATHER COLLINS MONTGOMERY FNP (NPI 1629203310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629203310 NPI number — HEATHER COLLINS MONTGOMERY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
HEATHER
Provider Middle Name:
COLLINS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629203310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6918 SHALLOWFORD RD
Provider Second Line Business Mailing Address:
STE 206
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-1782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-802-1919
Provider Business Mailing Address Fax Number:
423-269-6178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6106 SHALLOWFORD RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-802-1919
Provider Business Practice Location Address Fax Number:
423-269-6178
Provider Enumeration Date:
05/25/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  14126 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130529501F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1517467 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2009001637 . This is a "ANCC CERTIFICATION" identifier . This identifiers is of the category "OTHER".